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Doctors’ Notes: Sleeping pills aren’t the only answer

I’ve received a number of letters from readers about my recent Doctors’ Notes column on seniors and sleeping medications. Many people are doing their best to avoid potentially harmful and addictive sleeping pills, which is great to see. I asked my colleagues at North York Family Health Team, social worker Emelyn Barlett and pharmacist Eric Lui, to help me answer some of your most common questions.

I take the herbal medication melatonin to help me sleep, and I am wondering if it has any side effects I should be concerned about?

Melatonin is among a number of different herbal remedies to help promote sleep. Some popular herbal products may mix a number of the following ingredients: melatonin, a hormone produced by the body at night during periods of less activity; 5-HTP, a plant-based amino acid; theanine (also known as L-glutamine), a green tea extract; and valerian and camomile, which are both derived from plants.

While these are generally safe and well tolerated by most people compared to prescription sleep medications like benzodiazepines, the science behind these herbal remedies is still new. There is a lot we don’t know, including whether they are effective or safe for long-term use.

While herbal remedies have not been associated with some of the side effects of prescription sleep medications such as falls, memory problems, potential for addiction and potential for withdrawal, they do have reported side effects. They all affect alertness to some degree and may have drug interactions. There are other side effects for patients to watch out for. Reported side effects of melatonin include headaches, confusion, irritability, depression and stomach upset. In some rare cases, it may also increase the risk of seizures in certain people, and interact with some prescription medications like blood thinners. 5-HTP may cause dizziness and stomach upset, and has reported interactions with antidepressants and St. John’s Wort.

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While some patients have positive results with herbal remedies, it is still a good idea to talk with your doctor, pharmacist or other health-care provider about whether these are right for you.

I’m concerned that my mother is dependant on sleeping pills, but I worry that if I bring it up with her doctor, they’ll yank them away and she’ll have major withdrawal symptoms. How can I talk to them about my concerns?

This is a real fear of patients and their caregivers. Breaking the cycle of dependency means everyone — patients, families and health-care providers — need to work together. Large studies show the best approach to minimize withdrawal from addictive medications is “tapering.” This is where medication is reduced very slowly over time to minimize symptoms of withdrawal. One reader’s letter described how it took her three years to fully feel like herself again after gradually tapering off an addiction to Valium for sleep. I really applaud her and her health-care providers for engaging in this difficult task. It takes patience and persistence. However, it can be done and in her words, “I have my life, and my mental health back!”

Are there drug-free methods to help me sleep better?

Some readers shared ways they help sleep better without drugs, including being more active during the day, changing their bedroom to turn off screens from smart phones or televisions, and modifying eating or drinking habits so that they are not needing to use the bathroom throughout the night.

Another proven method of improving sleep is called Cognitive Behavioral Therapy (CBT). This is a form of psychotherapy that involves changing attitudes and behaviours, in order to increase positive associations with sleep. CBT has been suggested by large medical and pharmacist organizations as a better first treatment for insomnia than prescription medications. It has been shown to be as effective as taking sedative hypnotic drugs, such as benzodiazepines, to improve sleep.

CBT is also a commonly used, non-drug based treatment for other medical and psychiatric issues including cancer, chronic pain and depression. Studies have found that it may help with the symptoms of these diagnoses, which often include trouble falling or staying asleep.

The Choosing Wisely Canada campaign suggests the following general questions to ask your health-care provider.

Dr. Kimberly Wintemute is an assistant professor at U of T’s Department of Family and Community Medicine and a family doctor in North York. She serves as primary care co-lead at Choosing Wisely Canada. Doctors’ Notes is a weekly column by members of the U of T Faculty of Medicine. Email doctorsnotes@thestar.ca .

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